APRIL 2010: In Residency

Friday, April 09, 2010

by Shannon Gulliver

Spanish for Doctors

Warning to patients: I am about to be your doctor, and I cannot speak Spanish.

This was a surmountable problem in medical school, when I had all the time in the world to call interpreters on the wards. As an intern, every second matters, and clinical pressures can drown out the best intentions to call for translation.

The idea that I should know Spanish was not a revelation I struck upon when I hit the floors as an intern. Spending four years at P&S, in the heart of “Dominican Heights,” I knew Spanish was important all along. But it did not seem so pressing early on: In the first two years of medical school, the science, rather than the art, of medicine was the focus of the curriculum. For me, those years were spectacular: the molecules all followed their mechanisms of action and the drugs all reached therapeutic levels. The patients on the pages of the textbooks recovered or died, but either way they taught us a lesson.

Alongside these patients who had pathologies but not personalities, we also learned, in very general terms, how to be sensitive to the ethnocultural differences among patients and to the diverse attitudes toward medicine that these differences engender. Medical Spanish classes were offered, on Monday nights, for a fee. They conflicted with gross anatomy review sessions, though, so after learning to sing “Head, Shoulders, Knees and Toes, Knees and Toes” in Spanish during the first class, I felt compelled to devote my Mondays to learning the anatomy of the head, shoulder, knees, and toes in medicalese instead.

Indeed, gross anatomy gave me my one real patient during those first years, and with her I built a great rapport, examining her night and day and on the weekends, coming to know her intimately. She taught me about heart disease, atherosclerosis, and obesity. Language was never a problem between us: she was dead.

Rapport was not so easy to achieve with my first live patients in the latter years of medical school. I was eager to talk to them and mortified when I found that I couldn’t. Spanish-only speaking patients comprised a significant portion of my first clinical encounters, and even when I used interpreter services, I felt that I was missing something. I wanted to understand my patients’ problems, the cultural and ethnic predispositions they had to their afflictions, and the barriers to care they faced. At the same time, I could not help being frustrated with my own inability to speak their native language. I yearned for the classroom years, when ObesityHypertensionHeartDiseaseDiabetes was The Metabolic Syndrome, a disease on the page of a textbook, rather than a collection of concerns that I could not discuss with my patient in a language we both knew.

To what lengths should doctors go? Should we be required to learn Spanish along with the thousands of drugs, diseases, and molecular mechanisms we must commit to memory during our training? Whose responsibility is the lingual disconnect between the provider and her patient? To be sure, patients from far-away countries will find themselves in a hospital where no one can speak their language, and in New York we have excellent interpreter systems for such instances: From any phone, a clinician can dial an AT&T translation service in 160 languages. The problem is not the Urdu speaker. Neither the patient nor the doctor expects to get by without a phone interpreter. The problem is the Spanish speaker, who is more likely to be spoken to in scrappy doctor-Spanish than through an interpreter.

Why? Doctors like to think of themselves as a valiant bunch. They will try their best to muddle through a patient interview in their college-level Spanish rather than bother a native-speaking nurse, or keep the patient waiting longer while a live interpreter is paged. This is a valid effort. We are instructed not to interrupt the flow of an ER or inpatient unit by asking nurses to stop what they are doing to translate. We are instructed not to use family members who may skew what the patient says. We are supposed to always page professional interpreters when we are not totally comfortable conducting a medical interview in the patient’s native language. But how are doctors – especially inexperienced interns – meant to judge their own comfort with the language in the midst of discomfort about the other five patients waiting to be seen, the potential urgency of the patient’s problem (can time be wasted on nuances of listening comprehension when the patient is having chest pain?), and the pressure to move on to the next task in the hospital?

Perhaps physicians in regions where Spanish predominates should have Spanish language certification similar to CPR certification. Just as a more advanced version of CPR certification is required in the OR than is required in an outpatient clinic, perhaps a more advanced version of Spanish certification should be required to work in a psychiatric clinic (where language is paramount) than in the OR (where language is less so).

This seems like common sense, but the expectations for doctors and their Spanish skills are fuzzy. To be admitted to most U.S. medical schools, applicants must have a foreign language, but that language could be French, or German, or even Latin. If Spanish proficiency were a prerequisite for admission to medical school, and maintenance courses were part of the curriculum, the fuzziness might clear. Different levels of proficiency and fluency would be required for different specialties, but all medical students would graduate with a degree of competence in a language that, depending on their practice setting, they may encounter more frequently than English.

Why can’t we rely on doctors to learn Spanish on their own? Though medical students and doctors are exceptionally good at meeting the requirements with which they are faced, they are so overwhelmed by them that, even with the best intentions, optional tasks may get shortchanged. But give a premed/medical student/resident/attending another mandatory task, and it will absolutely get done. For the sake of our patients, we had better be forced to do it. Expert knowledge of diseases and drugs, ethnocultural sensitivity, and bedside compassion do not a good doctor make if he or she does not have sufficient language skill to deliver them.

Having moved from the medicine floors to the psychiatric wards of my chosen specialty, the question of Spanish has become, in a way, easier: there is no way I or anyone else without native Spanish would attempt a psychiatric encounter without an interpreter. The fuzziness is moot. But I feel for my colleagues back on the medicine floors, many of whom speak[ish] Spanish, who are answering three pages, trying to draw an ABG, and trying to determine whether a Spanish-only speaking patient’s chest pain has improved all at once. Instead of calling the interpreter, simply asking “Dolor?” can be considered dangerously sufficient in the face of simultaneous clinical demands. While this shortcut might be understandable, it is not acceptable. As doctors in an increasingly Spanish-speaking country, we need to consider the place of this language in the U.S. medical school curriculum.

Shannon Gulliver is a first-year resident in psychiatry at NewYork-Presbyterian/Cornell. Her article published June 28, 2010, in the New York Times “Cases” column can be found here.